"It's time to take the radical step of privileging correct information over incorrect information." (Rachel Maddow, 2/6/2009)
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Tuesday, October 27, 2009

Exactly Right on Health Care

The "media watchdog" debates on the WH versus Faux News dust-up consistently bring up "that other ideological news station" MSNBC, they always bring up Maddow and Olberman, and they equate what Olberman and Maddow do with what Faux does. I mean, they are both ideological, right? What they don't seem to understand, in their "balance-addled" brains, is that Maddow and Keith deal in objectively, demonstrably true things, and Faux deals in demonstrably false things. When Maddow and Keith get soemthing wrong, they issue a correction. When Faux gets something wrong - well, it's nearly all wrong, they expand on it. Somehow, in the minds of the media mavens, those two things are the same. Explains a lot. With that in mind, consider how perfectly Rachel frames the options in the following piece. Brilliant.Big asterisk on Reid's public option Oct. 26: Rachel Maddow is joined by Sen. Ron Wyden, D-OR, to assess the public option to be included in the Senate health reform bill.

Was out of the office for a few hours at C-SPAN world headquarters, but early reports were accurate and Sen. Reid will include a national public option that states could choose to offer to their residents -- or not! -- in his bill. In the Senate, this is about to become the "liberal" half of the debate. But it's not very liberal at all. It is a compromise, and a conservative one at that.
For the real liberals, the public option was already a compromise from single-payer. For the slightly less radical folks, the public option that's barred from partnering with Medicare to maximize the government's buying power was a compromise down from a Medicare-like insurance plan. For the folks even less radical than that, the public option that states can "opt out" of is a compromise from the straight public option. Access to the public option will be a political question settled at the state level. It is not a settled matter of national policy.
In many ways, this is a fundamentally conservative approach to a liberal policy experiment. It's only offered to individuals eligible for the insurance exchanges, which is a small minority of the population. The majority of Americans who rely on employer-based insurance would not be allowed to choose the exchanges. From there, it is only one of many options on the exchange, and only in states that choose to have it. In other words, it has been designed to preserve the status quo and be decided on the state level. Philosophically, these are major compromises liberals have made on this plan. They should get credit for that.

Sen. Sherrod Brown (D-Ohio) has been one of the Senate's leaders on the public option. His strategy, in large part, has been to emphasize how many Democrats support the idea, in comparison to the few that oppose it. Today, his work paid off, and the Senate will be considering a bill with a version of a national public option. I spoke to Sen. Brown about whether this is a good compromise, what will happen with Olympia Snowe, and why Democrats don't talk about Medicare more. A lightly edited transcript follows.What do you think of the compromise proposal?
I think it's good. Sen. Reid listened to his senators. There's clearly more than 50 votes for a strong public option. He listened to the voters. Public option polling showed two to one in favor of it. And he listened to the doctors. The Robert Woods Johnson foundation surveyed doctors and found 70 percent were for it. And he personally is very much for it.Olympia Snowe has said she won't vote for the bill if it contains a public option. Ben Nelson has made similar noises. Will a couple of moderates have a hammerlock on this legislation?
I don't think so. Two reasons. First, I don't think any Democrat wants to be the person who killed the most important Democratic initiative of their lifetime on a procedural vote. They may vote against the bill. But I don't think they vote against it on cloture. Second, I've done a bit of writing on Medicare in the 1960s. In those days, there were Rockefeller Republicans, which don't exist anymore except for Snowe. Collins isn't really one of them. But a lot of the Republicans voted no. And many of them had buyer's remorse a year or two later. Some number thought later that that was the wrong vote. And pretty clearly it was the wrong vote. It may not be till the conference report. But I think we're going to see more votes than predicted. You've seen a bit of that with former Republican Senate leaders like Bob Dole, Bill Frist and Howard Baker all coming out in favor of reform. They've all said, essentially, we missed our chance on this. Don't miss yours. What is it that makes this so much harder in office than out of office?
They don't have the right wing wackos blowing in their ear. Anybody with any decency and perspective watching this saw how the right wing so overreached by out-and-out lying and scaring people. American politics is replete with examples of politicians playing to fear. But people are desperate. I stand on the Senate floor every day and read a half-dozen stories from letters sent by people in Ohio. Most of the people who write would have said a year or two ago that they were happy with their health care, but then they had a baby born with a preexisting condition, or they got hit with an out-of-pocket cap, or they're facing rescission on a technicality. And then there are the people in their 50s who just pray that they make it until they get onto Medicare. And that anxiety is so sad. Even when senators represent the same constituencies, though, they often vote in different ways. Grassley and Harkin, for instance, both represent Iowa but aren't likely to vote the same way on health-care reform. You and Voinovich aren't likely to line up together on this. Why does this happen?

The ideological spectrum left to right is pretty meaningless to voters. If you believe in the continuum, then the Democrat or Republican who can grab the center wins. But it's ultimately about whose side you're on. One out of four voters in Ohio in 1988 voted for [liberal senator] Howard Metzenbaum and George W. Bush. Some fairly high percentage of Metzenbaum's voters called Metzenbaum a conservative. And the reason they did was they were conservative, and he fought for them, so in their minds, he was conservative. Will this bill get credit for being a compromise? After all, it's a compromise down from single-payer, down from a Medicare-like public option, and down from a national level-playing field public option.
Sen. Kennedy originally asked Sheldon Whitehouse and me to write the public option. But it became bigger even than I, a strong supporter of it, think it is. Progressives don't think it's a good bill unless it's in it. Conservatives think it isn't a good bill because it's in it. But this is good language because the state compromise isn't giving away too much. It won't put insurers out of business. But it will make them behave better. And at this point, we've compromised three times, and I haven't seen anything from the other side.
The problem with talking about Medicare is that if I asked 50 people on the street about Medicare, even if they were under 65, I'd get 85 percent support. But we in Congress hear from doctors who complain about reimbursement, device manufactures who complain about revenues, rich people who talk about government screwing everything up. I think the right way to sell this was based on Medicare. But my colleagues don't see it that way. As soon as we linked it to Medicare in the House, we lost votes.

In a good way. He slaps Fred Hiatt of the Washington Post hard, and he’s right to do so: Hiatt attacks the Senate Finance health bill for failing to include cost-control measures that, um, are very much in the legislation.
But Orszag professes confusion about what’s going on, whereas I’m sure he understands it perfectly. Hiatt is one of those people who, as Dan Gross puts it, is “bedeviled by the haunting fear that someone, somewhere may be getting social insurance.” All the talk of fiscal responsibility isn’t sincere — or, if you like, people like Hiatt, Robert Samuelson, and many others won’t accept any version of fiscal responsibility that doesn’t involve gutting Social Security and Medicare.
But they can’t quite say that, so they always pretend to have some other complaint about proposed reform. And if the complaint is completely bogus, who cares?

As I have said repeatedly — and as my colleague, Christy Romer, is discussing today at the Center for American Progress — reducing health care cost growth is the key to our fiscal future. To anyone who has studied our fiscal facts, this central conclusion seems indisputable.

And yet — perhaps because of the long-standing (and sometimes warranted) skepticism toward government, the fiscal irresponsibility of recent years, or just the generalized jaundiced view that journalists often like to project — every few days, there seems to be another commentator who fails to believe that we can pass deficit-neutral health insurance reform that also puts us on a path to reduce the deficit over the long term.

Fred Hiatt in today’s Washington Postis the latest of these naysayers, writing in his column that the two biggest steps that can be taken to reduce the rate of health care cost growth — changes in health care’s tax treatment and an independent Medicare commission — are missing. I agree with Hiatt on the potential substantial benefits in terms of cost containment from these two changes. But a note to readers who have not read their Washington Post the past few weeks: the Senate Finance Committee bill includes both of these measures.

Indeed, that committee’s final mark creates an excise tax on insurance companies offering high-premium plans — which would create a strong incentive for more efficient plans that would help reduce the growth of premiums. And it establishes a Medicare commission — which would develop and submit proposals to Congress aimed at extending the solvency of Medicare, slowing Medicare cost growth, and improving the quality of care delivered to Medicare beneficiaries.

If the concern is that these two provisions would not survive the rest of the congressional process, then say that — rather than suggesting that they aren’t already reflected in legislation.

Moreover, as I blogged a couple of weeks ago, the Senate Finance Committee’s bill is not the only measure that includes important cost constraining provisions. The other bills in the House also include provisions that experts from across the spectrum agree will help transform health care so that it delivers higher quality care and constrains cost growth. From penalties for hospitals with high, preventable 30-day readmission rates to encouraging the establishment of accountable care organizations and bundled payments for high-cost, chronic conditions, these bills undertake many of the reforms that hold the most promise for controlling costs and boosting quality.

Hiatt writes that "no one knows for sure how to control costs." True, we have never transformed the health sector before, and it is therefore difficult to quantify precisely how these steps will work together to promote quality and reduce cost growth. But it is wrong to conclude that these steps — even the ones beyond the excise tax on high-cost plans and the Medicare commission — are merely hypothetical pie in the sky. They represent what independent analysts and bipartisan groups such as the Engelberg Center at the Brookings Institution all say hold the most promise. In addition, recognizing that we need flexibility to adjust measures in a dynamic health care system, many of the bills start programs as pilot projects that can be quickly scaled up as results come in, and a Medicare commission too will be able to respond to changes as the health system evolves.

As the contours of the Senate and House bills are still being hammered out, we can’t lose sight of how far we’ve come — and how close we are to reform that could help move the health system in a healthier direction. As the President has repeatedly emphasized: Doing nothing is the surest way to fiscal failure, while reform is the best path for fiscal responsibility.

1 comment:

Bill Foege gave a lecture at CDC yesterday, in honor of the 30th anniversary of smallpox eradication (32 years since the last case was identified). He’s a truly insightful man (former EIS officer, a key player in smallpox eradication, former director of the Carter Center, former director of CDC, etc) and his lectures never disappoint me.

He concluded his talk yesterday by emphasizing the importance of surveillance systems to addressing what he considers to be the four major challenges to public health in the US currently: (1) the need for mental health statistics, (2) standard measures of climate change’s impact on human and environmental health, (3) continued focus on social determinants of health, and (4) healthcare reform. For healthcare reform, he suggested surveillance data could allow policymakers to use actual health indicators like reduction of obesity/chronic disease rates to better assess the quality of healthcare available to the population, and to make evidence-based decisions, as opposed to purely political ones.

He then went on to say that when he first began his career, everyone told him to watch out for socialism, so he spent years watching over his shoulder for socialism. He said that what he didn’t realize at the time was that he should have been watching over his shoulder for capitalism. He said something along the lines of: Capitalism is gaining on us. Our healthcare mess is due to capitalism. Some things do not lend themselves to the marketplace. One year after the marketplace let us down, we think it can solve our healthcare problem?

The lecture really recharged my batteries. It can be discouraging to constantly be exposed to cases and large scale trends of preventable morbidity and mortality amenable to our inadequate healthcare system. For example, outbreaks due to healthcare practitioners having to settle for less than the ideal method of diagnosis and course of treatment for their patient, because their patient cannot afford what he really needs. Additionally, physicians-- who are taught to do no harm-- are often unable to consult on primary prevention of disease because their practice is driven by limitations on time and resources.

Bill Foege ended by modifying a Democritus quote to say that the wise person belongs to all ages—learning from the past and working for the future. Especially with the volatile state of healthcare policy in US lately, I think everyone here at CDC really needed to hear his lecture yesterday—to meditate on what was learned from the smallpox eradication campaign, and to consider where we are now and what we need to do to move forward.